Although techniques for SMAS dissection and manipulation are numerous in the literature, the topics of skin flap vectoring and redraping are often overlooked. In this article, the authors detail a systematic method of skin flap vectoring and redraping to achieve consistent results.
1. SET THE APPROPRIATE VECTOR
The principle of differential vectoring relies on treating the face and neck as separate anatomic subunits. These subunits are delineated by the axis of the mandibular border at the level where it intersects the lobule. The neck subunit is redraped in a direction parallel to the mandibular border. (See Video 1 [online], which displays the appropriate vector of skin flap redraping for the face and neck subunits, the fixation of the postauricular flap, and the subsequent excision of scalp flap redundancy.) The facial subunit follows a more horizontal vector with a slight superior shift equaling the width of one tragus.
Video 1. This video displays the appropriate vector of skin flap redraping for the face and neck subunits, the fixation of the postauricular flap, and the subsequent excision of scalp flap redundancy.
2. POSTAURICULAR FIXATION
The postauricular skin flap is superimposed over the apex of the postauricular incision where it departs transversely to the scalp. It is split at the area of overlap and temporarily secured with a staple (Video 1). Splitting the flap separates it into two areas of redundancy: the scalp portion containing the hair-bearing portion, and the retroauricular portion along the sulcus. The scalp flap redundancy is excised, and the hair-bearing portion is closed with staples, aligning the apex of the incision first to prevent a dog-ear, followed by precise realignment of the hairline.
3. PERILOBULAR EXCISION
The retroauricular flap redundancy is then carefully excised at the retroauricular sulcus. (See Video 2 [online], which displays the key steps of retroauricular excision, helical root fixation, preauricular trimming, and temporal skin excision.) Maintaining redundancy at the otobasion inferius is preferable when nearing the lobule, which often reveals less perilobular redundancy than originally anticipated.
Video 2. This video displays the key steps of retroauricular excision, helical root fixation, preauricular trimming, and temporal skin excision.
4. HELICAL ROOT FIXATION
The preauricular skin flap is redraped along the previously discussed vector, split to the point where the superimposed flap overlaps the helical root, and temporarily secured with a staple (Video 2). This again creates two flaps of redundancy: a temporal portion and a preauricular portion.
5. PREAURICULAR TRIMMING AND TEMPORAL EXCISION
The preauricular redundancy is carefully trimmed, respecting the intricate contours of the peritragal region (Video 2). The senior author uses a free-hand approach to resect the obvious redundancy and performs further refinement of the tragal borders during closure. Alternatively, the flap can be split at the upper and lower tragal borders in a tailor-tacking fashion. The temporal skin excess is then resected.
6. CLOSURE
Three key fixation sutures are placed at the preauricular and postauricular incisions. (See Video 3 [online], which demonstrates placement of the three key sutures when closing the preauricular and postauricular incisions.) The most critical are the tension offloading sutures at the tragus and lobule. A 5-0 Polyglactin suture is placed just superior to the tragus to prevent tragal deformity. At the lobule, another suture is placed either through the perichondrium of inferior conchal bowl or through Lore’s fascia to prevent traction on lobule.1,2
Video 3. This video displays the placement of the three key sutures when closing the preauricular and postauricular incisions.
7. LOBULE INSET
The lobule is released from the underlying fascia, allowing for the skin flap to be interposed beneath it. This affords the ability to leave more tissue redundancy without creating fullness, while also avoiding a pixie-ear deformity. The lobule is retropositioned 30 degrees posterior to the axis of the mandibular border, or 15–20 degrees posterior to the long axis of the ear, and inset with 5-0 Nylon.3 (See Video 4 [online], which demonstrates the process of ear lobule inset.)
Video 4. This video demonstrates the process of ear lobule inset.
Footnotes
Disclosure: Dr. Rohrich receives instrument royalties from Eriem Surgical, Inc., and book royalties from Thieme Medical Publishing. Drs. Cason and Novak have no financial interests to declare in relation to the content of this article.
REFERENCES
- 1.Clevens RA, Baker SR. Plastic and reconstructive surgery of the earlobe. Facial Plast Surg FPS. 1995;11:301–309. [DOI] [PubMed] [Google Scholar]
- 2.Kaye KO, Casabona GR, Kästner S, et al. Correction and prevention of the pixie ear deformity: a combined technique. Aesthet Surg J. 2019;39:123–136. [DOI] [PubMed] [Google Scholar]
- 3.Connell BF. Neck contour deformities. The art, engineering, anatomic diagnosis, architectural planning, and aesthetics of surgical correction. Clin Plast Surg. 1987;14:683–692. [PubMed] [Google Scholar]